General and diabetes-specific stress in adolescents with type 1 diabetes
Introduction
Type 1 diabetes (T1D) is one of the most prevalent chronic health conditions in youth, affecting 1 in 400 adolescents in the United States, and its incidence is rising [1]. The recommended treatment regimen is complex and demanding [1]. Adequate self-management of the treatment regimen is often a source of significant stress for adolescents and their families [20]. Self-management of the treatment regimen requires coordination of multiple domains, including complicated decision-making, frequent blood glucose monitoring, regular insulin administration, and close attention to diet and exercise [1]. Adolescents must also coordinate regularly with parents and healthcare providers [1]. Appropriate self-management behaviors lead to better glycemic control, which reduces the risk of acute and long-term complications [2]. Despite the importance of maintaining adequate glycemic control, only 40% of adolescents engage in adequate self-management behaviors [16] and only 29% maintain HbA1c levels at the target level [32].
Adolescence is a stressful developmental period during which all adolescents experience significant physical, cognitive, and psychosocial growth. Adolescents undergo important physical changes during puberty, such as the development of secondary sex characteristics, which are driven by hormonal fluctuations [20]. Adolescents begin to develop advanced critical thinking and reasoning skills. Psychosocially, adolescents must navigate evolving social interactions with family members and peers, establish a sense of autonomy, and develop new self-conceptions [20]. While all adolescents must learn to manage general life stress, adolescents with chronic health conditions face additional stress related to the self-management of the condition. Disease-related stress has the potential to negatively impact both the condition as well as typical developmental tasks.
Adolescents with T1D often feel overwhelmed by the daily T1D-related stress that they face as found in qualitative studies. They describe diabetes as “difficult, demanding, and never ending” [7] and they describe diabetes care as a significant source of stress [7]. They have also described their daily lives as a “pendulum swinging between being normal and being different” [18]. In addition to diabetes-specific stress, adolescents with diabetes also report struggling with the same personal and social stress unrelated to diabetes that their peers without diabetes face, including social interactions with family and friends, as well as their own emotional and physical development [15].
Because adolescents with T1D face several types of stress, it is important to identify the differential effects of general life stress compared to diabetes-specific stress, so that more tailored interventions can be developed [10]. While it is known that stress negatively impacts glycemic control and self-management [9], [11], little is known regarding the specific impact of diabetes-specific stress compared to general stress during adolescence [15]. General and diabetes-specific stress has not been studied simultaneously, and the available studies have been primarily qualitative with small sample sizes [4]. Further research is needed to identify differences in the impact of general and diabetes-specific stress on adolescents with T1D. Thus, the purpose of this study was to examine the associations of general and diabetes-specific stress with glycemic control, self-management, and diabetes-specific QOL in adolescents with T1D. Our hypothesis was that general and diabetes-specific stress would be significantly associated with the primary outcomes, glycemic control, self-management, and QOL. We also wanted to determine if these two types of stress contributed equally or differently to the primary outcomes.
Section snippets
Methods
In this cross-sectional study, a secondary analysis of baseline data from a randomized control trial was conducted. The aim of the parent study was to evaluate the effect of an internet-based coping skills training program on glycemic control and QOL compared to an internet-based education intervention for adolescents with T1D [13], [29], [30].
Demographic
Demographic data (family demographics, including income, race/ethnicity, parent education, marital status, gender) were collected from parents or guardians. For this study, total family income was categorized as less than $40,000, $40,000–$80,000, or greater than $80,000. Age was a continuous variable. Race/ethnicity was dichotomized as white/non-Hispanic (64%) or non-white (36%). The non-white category included Hispanic/Latino (50%), Black or African American (30%), biracial (14%), or other
Data analyses
Descriptive analyses were conducted using ANOVA or Chi-square to test for demographic differences related to general and diabetes-specific stress. Bivariate Pearson correlations were conducted to examine the relationship between general and diabetes-specific stress with each other and with HbA1c, self-management, QOL, and covariates (race, gender, age, income, and therapy type [pump or injection]), and also to evaluate the effect of multi-collinearity. Multivariate linear regression analyses
Descriptive analyses
The final sample of 320 adolescents was 55% female and 62.2% non-Hispanic white, with a mean age of 12.3 ± 1.1 years (range 11–14 years), mean HbA1c of 8.46% ± 1.5, and mean diabetes duration of 6.1 ± 3.5 years. Approximately 63% of families had an annual income of <$80,000 and approximately 59% of adolescents used pump therapy (Table 1). The mean general stress score was 21.33 ± 7.9 (scores range from 0 to 56, with >20 indicating high stress) and the mean diabetes-specific stress score was 10.13 ± 4.6
Discussion
Results from qualitative studies demonstrate that adolescence is a stressful developmental period for youth with T1D. Our analyses provide quantitative support for these qualitative findings. In this study, adolescents reported high levels of both general and diabetes-specific stress, and higher levels of both types of stress were negatively associated with poorer glycemic control, self-management behaviors, and QOL.
In bivariate analyses, we found that adolescents from lower-income families
Conclusion
Despite these limitations, there are several clinical and research implications. Potential clinical and research implications include: (1) adolescents with T1D report clinically high levels of general and diabetes-specific stress; (2) adolescents from lower income families are more vulnerable to general stress than adolescents from higher income families; (3) adolescents with high levels of general and diabetes-specific stress may be at risk for poorer HbA1c, self-management activities, and
Conflicts of interest statement
The authors of this manuscript certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or
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